How do you prepare amiodarone (antiarrhythmic medication) for intravenous (IV) infusion?

Amiodarone Preparation for Intravenous Infusion

Prepare amiodarone by diluting it in dextrose 5% in water (D5W) using glass or polyolefin bottles, and deliver it through a volumetric infusion pump with an in-line filter, preferably via a dedicated central venous catheter. 1

Critical Preparation Requirements

Diluent and Container Selection

• Use only D5W (dextrose 5% in water) as the diluent for all amiodarone infusions 1
• Use glass or polyolefin bottles exclusively for infusions exceeding 2 hours 1
• Never use evacuated glass containers for admixing, as incompatibility with buffer in the container may cause precipitation 1
• Do not use plastic containers in series connections, as this could result in air embolism 1

Concentration Guidelines

• For infusions longer than 1 hour, do not exceed 2 mg/mL concentration unless using a central venous catheter 1
• Concentrations greater than 3 mg/mL are associated with high incidence of peripheral vein phlebitis 1
• Concentrations of 2.5 mg/mL or less are less irritating to peripheral veins 1
• Acceptable concentration range is 1-6 mg/mL when using a central venous catheter 1

Standard Dosing Preparation

Loading Dose (First 24 Hours)

• Rapid loading bolus: Mix 150 mg in 100 mL D5W for infusion over 10 minutes 2, 3, 1
• Early maintenance: Prepare 360 mg (1 mg/min × 6 hours) in appropriate volume of D5W 2, 3, 1
• Late maintenance: Prepare 540 mg (0.5 mg/min × 18 hours) in appropriate volume of D5W 2, 3, 1
• Total first 24-hour dose should be approximately 1000 mg 1

Breakthrough Dose Preparation

• Mix 150 mg in 100 mL D5W for supplemental infusions during breakthrough ventricular fibrillation or hemodynamically unstable ventricular tachycardia 1
• Infuse over 10 minutes to minimize hypotension risk 1

Equipment and Administration Setup

Required Equipment

• Use a volumetric infusion pump (mandatory—drop counter sets can underdose by up to 30% due to altered surface properties) 1
• Use an in-line filter during all administrations 1
• Administer through a central venous catheter whenever possible, dedicated to amiodarone 1

Tubing Considerations

• PVC tubing is acceptable (all clinical experience has been with PVC tubing) 1
• Be aware that amiodarone leaches plasticizers (DEHP) from PVC tubing, though this reflects standard clinical practice 1
• The degree of leaching increases with higher concentrations and lower flow rates 1

Critical Safety Precautions

Preparation Warnings

• Never exceed initial infusion rate of 30 mg/min 1
• Loading infusions at much higher concentrations and faster rates than recommended have resulted in hepatocellular necrosis, acute renal failure, and death 1
• Mean daily doses above 2100 mg are associated with increased risk of hypotension 1

Pre-Administration Checks

• Inspect solution for particulate matter and discoloration before administration—solution should be clear 1
• Amiodarone does not need protection from light during administration 1

Drug Incompatibilities

Y-Site Incompatibilities

• Amiodarone in D5W forms precipitates with certain drugs and requires separate IV lines if coadministration is necessary 1
• Check specific Y-site compatibility before mixing with other medications 1

Common Pitfalls to Avoid

• Never use drop counter infusion sets—they will underdose by up to 30% 1
• Never use concentrations >2 mg/mL for peripheral IV infusions lasting >1 hour (high phlebitis risk) 1
• Never prepare in evacuated glass containers (precipitation risk) 1
• Never use diluents other than D5W (incompatibility) 1
• Never infuse faster than 30 mg/min initially (risk of hepatocellular necrosis and acute renal failure) 1